ARC® Fertility Articles

A Journey through an In Vitro Fertilization (IVF) Cycle

Cameron John Mullinder’s birth in late 2006 was a milestone. His mother, Louise Brown, was the first in vitro fertilization (IVF) baby in the world, born in England in 1978. Her birth generated a firestorm of criticism. His birth was a mere curiosity. Louise Brown’s conception by combining sperm and egg in the laboratory caused great fear that science had outpaced morality, that humankind had exceeded forbidden boundaries. Yet now, 30 years later, IVF is part of the treatment options offered by most full-service infertility programs. Thousands of babies have been born following IVF. In the U.S. alone in 2006, more than 100,000 IVF procedures were performed, resulting in more than 30,000 babies. The doom and gloom that this method of conception created about unintended defects have given way to the recognition that it has helped countless couples achieve their life-long dream to become parents to healthy children.

What is in vitro fertilization (IVF)?

In Vitro (Latin) means “in the glass” or “in the laboratory”. In vitro fertilization means “fertilization in the laboratory”, or the procedure in which the sperm and eggs are placed together in the laboratory and fertilization occurs, resulting in fertilized eggs (embryos).

Who needs IVF?

While damaged or absent fallopian tubes were the original indication for IVF, most IVF procedures are now performed because of abnormalities in the sperm (male factor infertility). Unexplained infertility is the second most common factor leading to IVF, followed by tubal factor, ovulation problems, endometriosis, and uterine factors. Generally, couples with severe male factor infertility, damaged fallopian tubes, prolonged infertility (more than 3 years), severe endometriosis or scarring (adhesions), or with failure to get pregnant after using other fertility procedures, are suitable candidates for IVF.

The IVF Journey

This is a lengthy, stressful, expensive journey without guarantee for success. This is also a quest for the most precious reward that a couple may ever seek – a baby. My role as a physician is to guide you confidently and competently from start to finish, trying to reduce unwarranted stress and apprehension. Good preparation is very important, as with any important journey. Once the physician determines that IVF is medically appropriate, the couple must then determine if IVF is the appropriate procedure for them from their own ethical, spiritual, physical, and financial standpoint. An extensive consultation with a qualified physician is therefore warranted.

Preliminary evaluation for IVF must include evaluation of the uterus and fallopian tubes, preferably by hysterosalpingogram (HSG, x-ray of the uterus and tubes) or sono-hysterogram (ultrasound with fluid). Abnormalities of the uterus such as fibroids, polyps, scar tissue, or distortions from birth must be repaired before the IVF procedure. If the female partner is older than age 35, evaluation of her ovarian reserve should be performed, usually by a clomiphene challenge test (CCCT) and assessment of antral follicles by ultrasound. Poor or marginal ovarian function merits serious consideration for alternatives to IVF with the female partner’s eggs, such as egg donation or adoption. A special semen analysis performed under the same conditions as during the IVF process (the semen “IVF screen”) should help in determining whether conventional IVF, or IVF with intracytoplasmic sperm injection (ICSI), is appropriate.

At our institution, the couple is asked to attend an IVF class, where one of our nurses and one of our embryologists explain the “nuts and bolts” of the IVF process in detail. This is a 1-2 hour class, usually attended by several couples, that our patients have found extremely helpful in clarifying the process. Each couple will then individually communicate with one of our nurses about their own start time, approximate egg retrieval and embryo transfer dates, and the specific ovarian stimulation protocol for them. Financial arrangements must be made prior to starting the process. A bank loan program is available for couples. They should contact Bennett Fertility Institute (405-949-6060) if interested.

The IVF process usually lasts 7 weeks. The female partner will be seen only twice during the first 5 weeks. These 5 weeks are the “ovarian suppression” period, where usually birth control pills (3 weeks) and Lupron daily injections (2 weeks) are taken. In the first few days of the designated menstrual period for cycle start, the patient is seen for an ultrasound and transfer catheter trial. This is called “mapping and mock cannulation”, a “dress rehearsal” to the actual embryo transfer on week 7. Four to five weeks later, another ultrasound is performed (“suppression check”) to ascertain that the ovaries are now at a state of rest prior to stimulation with fertility injections.

Week 6 is a busy one. The patient will take several injections per day to stimulate the formation of several eggs in the ovaries. She is usually seen 4 times for brief visits consisting of an ultrasound and blood work. On week 7, egg retrieval and embryo transfer will take place. The egg retrieval procedure is performed under IV sedation and lasts 20-40 minutes. Under ultrasound guidance, while the patient is asleep, a needle will be inserted twice in the vagina and ovarian follicles containing eggs will be emptied. After approximately one hour of recovery, the patient will go home, usually resting for several hours before resuming activities. Three to five days later, embryo transfer will be performed while the patient is awake. This simple procedure, similar to the “mock cannulation” earlier, lasts 10 minutes. The patient will then rest at home for 2 days. The pregnancy test is performed 14 days following the egg retrieval procedure.

Will it hurt?

Yes, but you will tolerate it well. The vast majority of patients do. Remember – shots are scary but when you see short and thin needles that children with diabetes use 2-3 times daily, you will tolerate self-injection or even your husband giving you your shots quite quickly. Besides, it is only for several weeks. The progesterone daily shots after the egg retrieval are uncomfortable but most patients tolerate them. After egg retrieval, your abdomen will ache for several days (much like menstrual cramps) but most patients do well even without pain medications. The embryo transfer is not painful.

How many embryos are transferred?

We try to transfer no more than 2 embryos in patients younger than 35 or if the embryo quality is good at an older age. This will be discussed with you before the IVF cycle and right before the embryo transfer. I will make a recommendation- you have the veto power. In most cases, we have no problems transferring less embryos than recommended, even one, than transferring more than we initially recommend. Remember- multiple births may be a tremendous challenge!

Birth defects? Chromosomal abnormalities?

Usually no more than non-IVF conceptions, except in cases with severe male factor, which may be caused by a genetic defect that may be transmitted to the children.

Why is it so expensive?

What happens behind the scenes, especially in the laboratory, is not usually apparent to the patient but may be the most expensive aspect. Sort of like the engine room of a large cruise ship. Maintenance, fuel, and other hidden expenses contribute to the expense of the cruise but are not apparent on deck. Meticulous quality control measures, technician time, materials, regular lab inspections, anesthesia, lab work, medications, and other issuess make IVF expensive.

What is your success rate?

IVF programs in the U.S. are obligated to report their results annually to the Society of Assisted Reproductive Technology (SART, www.sart.org) and/or to the Centers for Disease Control (CDC, www.cdc.gov). You may find the success rates for most programs on either of these Web sites. Please note that comparisons between programs may not be valid due to different patient populations, different selection and qualification criteria for IVF, and different protocols. You may wish to compare the results of your program of interest with the national average. For example, in 2006, live birth per IVF retrieval procedure at my program, Bennett Fertility Institute, was 61.7% for women under age 35, vs. national average of 42%. You may also check each program’s consistency by observing success rates over several years on www.sart.org.

Am I too old for IVF?

Generally, the younger the female partner, the greater the success in IVF. In the 23 years of Bennett Fertility Institute’s existence, we have not had a single viable pregnancy over the age of 43 unless it is from egg donation. This dismal birth rate per procedure is universal at this age. While we discourage women in their 40′s from undergoing IVF with their own eggs, if the couple understands the risks, costs, and success rates, we will go ahead with the procedure. Bear in mind that a woman in her 40′s faces very low pregnancy rate, high miscarriage rate, and relatively high rate of chromosomal abnormalities in the child.

What can I do as a patient to improve my success in IVF?

Reduction of stress and other adverse environmental factors is important. Stop smoking. Drink no more than 2-3 alcoholic drinks per week. Take prenatal vitamins. Engage in stress-reducing activities or therapies (moderate exercise, yoga, pilates, acupuncture, massage). Baby aspirin? steroids? Viagra? Incense-burning? Voodoo dolls? IVIG? Chinese herbs? Moxibuction? Let’s talk seriously about these and other alternative therapies that you may find on the Wild Web.